Management of Children with Severe Acute Malnutrition (SAM) is a National Priority to Achieve Reduction in Under Five Mortality

SAM Expert Group India

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Severe acute malnutrition (SAM) or severe wasting is defined by very low weight-for-height (below -3 z-scores of the median WHO child growth standards), a mid-upper arm circumference < 115 mm, or by the presence of nutritional edema. SAM remains one of the major killers of children under five; it contributes to approximately 1 million child deaths every year. Globally, it is estimated that 26 million children under five years are severely acutely malnourished, most of whom live in South Asia and in sub-Saharan Africa. India alone is home to 8,105,000 children with SAM (31.2 % of the world’s severely wasted children).

Most of the deaths caused by SAM can be averted. In recent years, there have been significant developments in the prevention and treatment of SAM. WHO and UNICEF recommend two major approaches to the treatment of SAM.

Facility/hospital-based approach for clinical management using the WHO protocol

Home/community-based approach, an integrated public health response to acute malnutrition without medical complications.

The summary below gives an overview of the scientific evidence on the contribution of SAM to child mortality; detection and management of SAM among children aged 6-60 months; and the management of SAM with other conditions (for example HIV/AIDS).

Child undernutrition and mortality

As stated above, SAM is a deadly condition. It kills children by increasing the case fatality of common childhood infections, and therefore it is an immediate or direct cause of child death. Malnourished children who are ill die because they are malnourished. Mortality rates in SAM children are 9 times higher than those in well-nourished children. According to the Maternal and Child Undernutrition Study Group, 3.5 million child deaths, 35% of the disease burden in children younger than 5 years, and 11% of total global disability-adjusted life-years (DALY) are attributable to maternal and child undernutrition1. It was estimated by the same group that stunting, severe wasting, and intrauterine growth restriction together were responsible for 2.2 million deaths and 21% of DALYs for children below five years of age.

A recent study in Senegal and Congo among children below 5 years found that severe wasting was one of the leading causes of death among under- fives, with a high incidence (about 2% per child semester), long duration of episodes, and high case fatality rates (6-12%)2.

Severe wasting is not the only form of malnutrition that kills children. A re-analysis of six published population-based studies of anthropometry-mortality indicated that mild to moderate malnutrition was associated with increased mortality and that there was an epidemiologic synergism between malnutrition and morbidity.

It appears from the current evidence that malnutrition has a far more powerful impact on child mortality than generally appreciated, and strategies combining prevention and treatment of mild to moderate, and severe acute malnutrition will be more effective to address this challenge and reduce its negative impacts.

Case detection of SAM using clinical and anthropometric assessments

Several clinical and anthropometric methods are commonly used for case detection of severely malnourished children aged between 6 and 60 months. These methods include the measurement of weight-for-age, mid-upper arm circumference (MUAC), and bipedal pitting edema. The complexity and cost of measuring weight-for-height make it unsuitable for use by community-based volunteers. A 2006 review of these different clinical and anthropometric methods with regard to their ability to predict mortality risk and reflect nutritional status revealed that MUAC < 110 mm, with the addition of presence of bipedal edema, is the indicator best suited for screening and case detection of child malnutrition in the community3.

WHO child growth standards and their implications

In 2006, the World Health Organization released new child growth standards. The introduction of these standards with the z-score criterion (weight-for-height < – 3 z-score) for identifying children for admission into SAM treatment programs has some important programmatic implications. Using < – 3 z-score implies the inclusion of children who are younger but have relatively higher weight-for-height on admission compared with the National Center for Health Statistics (NCHS) reference that uses weight-for-height <70% of the median criterion for SAM case detection. Using the WHO standards in developing country situations results in 2-4 times increase in the number of infants and children falling below – 3 SD compared to using the former NCHS reference. The introduction of the WHO child growth standards (and MUAC < 115 mm) to identify SAM children will increase the caseload for therapeutic feeding programmes, however at the same time, more children will be detected earlier and in a less severe state; thereby resulting in faster recovery and lower case fatality rates. Increasing numbers of children with SAM identified using the new WHO cut-offs has cost and human resource implications, especially in resource-poor settings.

WHO and UNICEF recommendations

WHO and UNICEF recommend the use of a cut-off for weight-for-height of below – 3 SD of the 2006 WHO child growth standards or a MUAC < 115 mm to identify infants and children (6-60 months) as having SAM4. The prevalence of SAM based on weight-for-height below -3 SD or a MUAC < 115 mm are very similar. The presence of bilateral edema remains another independent indicator of SAM.

With the new WHO standards, it was also essential to redefine the discharge criteria for in¬patient SAM children. It is recommended that the discharge criterion be based on percentage weight gain. For simplicity, it is possible to use 15% weight gain as discharge criterion for all infants and children admitted to therapeutic feeding programs.

The lower case fatality rates and slower weight gains of children selected by the WHO standards should be taken into account when monitoring the effectiveness of therapeutic feeding programs. To improve planning, it is vital that the same criteria are used for estimating caseload as are being used for admission into programs.

Facility/hospital-based management of SAM

The treatment of SAM occupies a unique position between clinical medicine and public health. Hospitals treating SAM are commonly challenged with extremely ill patients who need intensive medical and nursing care. Most of these medical care facilities are in the poorest parts of developing countries with severe capacity constraints, in particular, very few skilled staff. Additionally, the children’s caregivers come from economically disadvantaged families whose existence depends on daily labor. Admitting their children into a medical care facility puts great demands on their time and this should be taken into account to achieve an impact at a population level.

The case fatality rates for severe malnutrition treated in health facilities in resource-poor settings have remained high at 20-30% for marasmus and up to 50-60% for kwashiorkor5. The high case fatality rates in children with SAM can be substantially reduced by methodically following standardized treatment protocols such as the WHO protocol for in-patient management. The core of the accepted WHO management protocol is 10 steps in two phases – stabilization and rehabilitation. These 10 essential steps are listed below:

Treat/prevent hypoglycemia;

Treat/prevent hypothermia;

Treat/prevent dehydration;

Correct electrolyte imbalance;

Treat/prevent infection;

Correct micronutrient deficiencies;

Start cautious feeding with F-75;

Achieve catch-up growth by feeding F-100 after appetite returns;

Provide sensory stimulation and emotional support; and

Prepare for follow-up after recovery6.

This approach requires many trained staff and substantial in-patient bed capacity. Adequate training of health staff in the management of SAM is essential if the WHO guidelines were to be effective.

Experience over the past decade indicates that the survival of malnourished children improves substantially if the WHO guidelines are followed systematically. A halving of deaths, from 40% to 20% has been regularly reported when the guidelines are followed to a large extent7 (e.g. special feeds day and night, antibiotics, electrolytes, avoiding intravenous fluids except in shock, and not giving diuretics for edema). Mortality can be reduced to below 10% when the guidelines are meticulously followed. This involves training of all incoming staff, careful supervision of junior staff, careful monitoring of intake to guide selection of oral or nasogastric feeding, careful monitoring during rehydration to prevent fluid overload, daily ward rounds to identify children with new episodes of diarrhea or illness, good hygiene to prevent nosocomial infections, attentiveness to danger signs, and diligence in performing all tasks. Specialized skills of experienced pediatricians are required to reduce mortality below 5% as these residual deaths are usually among very seriously ill children.

Successful implementation of the WHO protocol in hospital settings has been reported in studies from Bangladesh and South Africa where quality of care improved with implementation of the WHO guidelines and case fatality rates reduced8,9. However, it should be taken into account that these observations are from studies done in a few well-resourced hospital settings, with skilled and motivated health staff that is the major determinant of their success. In reality, access to suitable health facilities is often limited where it is needed most, and the skilled staff required is rarely available in resource-poor contexts. In another study to improve the hospital management of malnourished South African children, participatory research led to the formation of a hospital nutrition team, which identified shortcomings in the clinical management of severely malnourished children and took action to improve quality of care. These actions were associated with a reduction in case fatality rates.

Modifying WHO guidelines

The efficacy of protocols based on WHO’s modified guidelines has been tested in India and Bangladesh on a small number of children10,11. In both countries, it was found that following modified WHO guidelines is feasible, efficacious and cost effective in resource-limited settings. Early discharge of patients is possible with no complications or mortality. However, critical reviews of the modifications of WHO’s guidelines for the treatment of SAM indicate that while efficacious simplifications to these guidelines to suit local conditions and needs are welcome, they must be based on sufficient sample size.

This approach requires careful monitoring because nutrient adequacy is hard to achieve with mixtures of low-cost local foods combined with micronutrient supplements. Data suggest that it is not possible to attain the micronutrient content of milk-based therapeutic diets (F75 and F100) with local foods only. Nonetheless, these mixtures of family foods also make good complementary foods and have the potential to prevent malnutrition in the long term.

SAM and other infections

Infections such as HIV and tuberculosis increase the workloads of hospital units treating children with SAM. These infections raise the prevalence of SAM and increase the case fatality rates. Although experience in resource-poor sub-Saharan countries has shown that many HIV-positive children can recover normal nutritional status when given standard treatment protocols for SAM; their recovery is slower than that of uninfected children.

HIV infection is also associated with high rates of complication and case fatality. A study on management of SAM in areas of high HIV prevalence was carried out using (i) an initial inpatient phase, based on WHO guidelines, and (ii) an outpatient recovery phase using RUTF. The inpatient mortality and cure rates improved compared to pre-study data but the overall mortality rate did not meet international standards. Home-based therapy with RUTF was associated with more rapid weight gain and a higher likelihood of reaching 100% weight-for-height.

Home/community-based management of SAM

Evidence suggests that large numbers of children with SAM with no medical complications (60 – 90% of children with SAM) can be treated in their communities without being admitted to a health facility or a therapeutic feeding center12. Community-based management of SAM results in a substantial increase of program coverage and successful treatment of children leading to lower case fatality rates.

Community-based management of SAM is based on early detection and assessment of children with SAM in the community, and home-based care of those without complications. Those with complications, evidenced by loss of appetite, will still need facility-based treatment. This approach involving active case finding ensures that many children with SAM who usually remain undetected because their families do not seek care for them are reached.

The community-based component of the treatment of severe malnutrition should be closely linked with the facility-based component, so that children who are too ill to be treated at community level or who are not responding to treatment can be referred to the facility level, and those receiving facility-based treatment who have regained their appetite can be transferred for continued care in the community.

Experience in Ethiopia showed that in community-based therapeutic care13, families became key participants in the rehabilitation of their children, and communities became strengthened through the mobilization of local networks and the improved knowledge base of local health networks. Recovery rates were comparable with international standards, and coverage far exceeded that of traditional center-based care.

In other experiences in twenty-one community-based therapeutic care programs implemented in Malawi, Ethiopia, and North and South Sudan between 2000 and 2005 where 23,511 cases of SAM were treated, coverage rates were 73% and recovery rates of 79.4% and mortality rates of 4.1% were achieved. Of the SAM children, 76% were treated solely as out-patients. The cost-effectiveness analysis of these programs indicated that the cost varied from US$12 toUS$132 per year of life gained14.

In addition, thirty-three community-based rehabilitation programs delivered by day-care nutrition centers, residential nutrition centers, primary health clinics, and domiciliary care with or without food from 1980-2005 were reviewed for their effectiveness. Effectiveness was defined as mortality of less than 5% and an average weight gain of at least 5 g/kg/day. It was found that all four delivery systems can be effective with careful planning and resources. However, it is unlikely that a single delivery system would suit all situations worldwide. The choice of a system depends on local factors. High energy intakes (> 150 kcal/kg/day), high protein intakes (4-6 g/kg/day), and provision of micronutrients are essential for success15.

A study in Malawi compared therapeutic feeding program coverage of severely malnourished children16 achieved by a community-based therapeutic care (CTC) program and a therapeutic feeding center (TFC) program operating in neighboring districts. Results revealed that CTC gave substantially higher program coverage than a TFC program. Findings of a study from Niger suggest that satisfactory results for the treatment of severe malnutrition can be achieved using a combination of home and hospital-based strategies.

Ready-to-use therapeutic food (RUTF)

Children with SAM need safe, palatable foods with high energy content and adequate amounts of vitamins and minerals. RUTF spread is an edible lipid-based paste that is energy-dense, resists bacterial contamination, and requires no cooking. The most widely used RUTF is a high protein and high energy peanut-based paste approved by the World Health Organization. The spread is a mixture of milk powder, sugar, vegetable oil, peanut butter, vitamins and minerals.

RUTF spread can be safely and easily produced in small or large quantities in most settings worldwide. Several countries in Africa such as Niger, Congo, Malawi and Ethiopia are manufacturing RUTF following appropriate technology transfer. Presently there is no indigenously available RUTF in India and it is time to manufacture it in partnership with industry and food technological institutes and pilot test on a programmatic scale.

The development of RUTF has allowed much of the management of SAM out of hospitals. In Malawi, a large-scale home-based therapy with RUTF yielded acceptable results with respect to recovery and case fatality of 6-60 month old children without requiring formally medically trained personnel17. In addition, 1-5 year old children with edematous malnutrition and good appetite were successfully treated with home-based therapy with RUTF.

A controlled, comparative, clinical effectiveness trial in Southern Malawi compared the recovery rates (defined as reaching a weight-for-height z score > -2) among 10-60 month-old children with moderate and severe wasting, kwashiorkor or both receiving either home-based therapy with RUTF or standard in-patient therapy18. It was found that home-based therapy with RUTF was associated with better outcomes for childhood malnutrition than standard therapy when compared on recovery rates, relapse, case fatality and prevalence of fever, cough and diarrhea.

During periods of food insecurity in developing nations, a recurrent challenge is to reach out to affected populations in rural areas where malnutrition is widespread but distance or geographic location makes health services inaccessible. These areas may also be without trained health personnel or a health care structure to treat malnutrition. In such situations, home-based therapy with RUTF is effective in treating malnutrition. For example in rural Malawi, home-based therapy and RUTF were used to successfully treat children with severe malnutrition by village health aides with nearly 94% of the children recovering from SAM. The results demonstrate that home-based therapy with RUTF administered by trained village health aids is an effective approach to treating malnutrition in areas lacking health services.

The efficacy of RUTF and F-100 in promoting weight gain in malnourished children was compared in 70 severely malnourished Senegalese children (6-36 months) who were randomly allocated to receive 3 meals of either F-100 (n=35) or RUTF (n=35) in addition to the local diet. It was found that the energy intake and the rate of weight gain were significantly greater in those receiving RUTF than in those receiving F-100, whereas time to recovery was significantly shorter in the RUTF group.
In India the acceptability and energy intake of imported RUTF was compared with cereal-legume based khichri among malnourished children 6-36 months19. RUTF and khichri were both well accepted. However, the energy intake from RUTF was higher due to its better energy density.

In Malawi, home-based treatment of 1-5 year olds with RUTF was successful in affecting complete catch-up growth20. In this study, locally produced and imported RUTF were similar in efficacy in treatment of severe childhood malnutrition. Results of a study from Senegal indicate that home-based rehabilitation of severely malnourished children with locally made RUTF was successful in promoting catch-up growth. The locally produced RUTF was as well accepted as the imported version and led to similar weight gain.

Psychosocial stimulation of children with SAM

Undernutrition in early childhood is associated with poor mental and motor development. Nutritional deficiencies and a lack of stimulation create a vicious cycle in which deprivation in one can result in further deprivation in other. For example, a malnourished infant may show reduced psychomotor activity such as crawling and engagement in creative play. As the child becomes more apathetic and less demanding, parents often provide less stimulation. The combination of malnutrition and a lack of psychosocial stimulation are particularly harmful. A cluster-randomized study in Bangladesh provided psychosocial stimulation for 12 months to undernourished children attending community nutrition centers. Children receiving stimulation had improved mental development and behavior and their mothers’ knowledge regarding child care practices increased as compared with the control group children.

To conclude, severe acute malnutrition among children under five years remains a major scourge in the developing world, including a booming economy like India. Investing in prevention is critical but treatment is urgently needed for those who are already malnourished. Until recently, treatment of SAM children had been restricted to facility-based approaches, thus limiting its coverage and impact. New evidence suggests that large numbers of children with SAM can be treated in their communities without being admitted to a health facility or a therapeutic feeding center. The community-based approach involves early detection of SAM and provision of treatment to those without medical complications with ready-to-use therapeutic food or other locally produced nutrient dense foods at home. If the community-based approach is appropriately combined with facility-based approach for malnourished children with medical complications at large scale, it could prevent the deaths of thousands.

Children’s lives can be saved by: (i) adopting and promoting national policies and programs that ensure that national protocols for the management of SAM have a strong community-based component (based, if necessary, on the provision of RUTF or locally produced nutrient dense food) that complements facility-based activities, achieve high coverage of interventions for identifying and treating children through effective community mobilization and active case finding, provide training and support for community health workers to identify children with SAM who need urgent treatment and/or referral, provide training for improved management of SAM at all levels; (ii) providing the resources needed for management of SAM, and (iii) integrating the management of SAM with other health activities such as preventive nutrition initiatives (promotion of breastfeeding and appropriate complementary feeding, provision of relevant information, education and communication materials), and activities related to the integrated management of childhood illnesses at first-level health facilities and at the referral level, and initiating such activities where none exist.

Myatt, M., Khara, T. & Collins, S. (2006) A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food and Nutrition Bulletin 27(3 suppl):S7-S23.

WHO child growth standards and the identification of severe acute malnutrition in infants and children. A joint statement by the World Health Organization and the United Nations Children’s Fund, 2009.